(February 2011) For more than 20 years, since the first data collection in Sudan in 1989, the Demographic and Health Survey (DHS) team at Macro International has been tracking the prevalence of female genital cutting (FGC), also known as female genital mutilation and female circumcision. The female genital cutting module consists of a series of 20 questions, and countries in Africa where FGC is practiced usually use this module in their national surveys. What is the FGC module? What is the information this module collects? How have the questions asked in the DHS modules changed over the years? In a PRB Discuss Online, P. Stanley Yoder, social anthropologist and senior research specialist at ICF Macro, answered questions from participants about the survey process and female genital cutting in Africa.

Feb. 7, 2011 12 PM (EST)

Transcript of Questions and Answers

Richard Cincotta: Given the provocative title, I can only think: Why should the FGC module have changed? Did researchers running the African DHS learn things about FGC that made them doubt questionnaire results, or want to deeper to understand FGC practices and impact?
P. Stanley Yoder: Thanks for the question, Richard. The DHS group has been collecting data on FGC since 1990. In our occasional discussions about how we might improve the FGC module, several issues have often been raised. One is the challenge of how to ask about what was done to a respondent when she was cut. We were not certain a woman would know or remember, and we were unsure about how to ask. The WHO has their classification into three main types, and we are all especially concerned about the impact of infibulations on women’s health. So the way we ask about types has changed. Our current series of questions gives us mainly rates of infibulation. We have also been unsure about the importance of asking about certain opinions: why the practice is continued, or the benefits of FGC. So several of those questions have been dropped recently. And our data can show trends over time for periods of ten or more years before the survey, since we ask about the status of women 15-49 years of age. So now we ask about the FGC status of all living daughters less than 15 years old. This allows us to monitor trends that are a bit more recent than before.

Elaine: Is Islamic history being used to combat FGM? In Ibn Ishaq’s “Seerat Rasul Allah” (Life of the Prophet of Allah) at the famous Battle of Uhud, Muhammad’s Uncle Hamzah insults his polytheist enemy by calling him a “son of a clitoris-cutter.” This illustrates that FGM was a pre-Islamic practice scorned by the early Muslims. Another early Muslim historian, al-Baladhuri, also includes this anecdote in his account. Is anyone showing these accounts to the Muslims who practice FGM?
P. Stanley Yoder: Thank you, Elaine. Scholars have long known that FGC predates Islam by many centuries. I do not think that programs combating FGC are using Islamic history to combat FGC, but many programs have made major efforts to demonstrate that Islam does not require that girls be circumcised. In countries such as Senegal, Mali, and Egypt, to mention only a few, anti-FGC programs have enlisted the assistance of imams to explain that Muslims need not circumcise their daughters. In the DHS surveys, we ask both male and female respondents if their religion requires that girls be circumcised.

Sanjay Mishra: How to change the traditional mindset of the people to abandon FGC is a big question in many parts of North Africa it is in practice at wider at wider level. If there is some visible positive impact in result by changing the module then it can be justified, but still can be said there is no proper data on the issue to estimate the exact impact.
P. Stanley Yoder: Sanjay, I am not sure what you are asking. Are you asking about the impact of FGC or the impact of anti-FGC programs? If the latter, the main way to assess program impact is to examine FGC prevalence over time, and that can be measured with population-based surveys, as we know. The questions of the FGC module provide such data. If you are thinking of the impact of the practice of FGC, we should speak more of its effect on women themselves. The WHO, for example, conducted a study in a number of sites in African countries to assess the impact of FGC on women. We can find a report of that study on the WHO web site.

Armelle Andro: The valuable DHS data have provided a better understanding of the evolution of FGC in Africa in a comparative sociological and anthropological perspective. But still now, are there any studies on the various impact of FGC on the levels of maternal mortality and morbidity in a more epidemiologic perspective in African countries?
P. Stanley Yoder: Thank you for the question, Armelle. The short answer is no, for if you mean by “epidemiologic” a study that is both population-based and with a large sample, such studies are complex and expensive to conduct. The study that comes the closest to what you are seeking may be the study sponsored by WHO and conducted in six African countries and published in 2006. You can find it on the WHO web site and in The Lancet 2006, 367:1835-1841. Carla Obermeyer also wrote several fine analyses of the literature some time ago that are well worth reading. Obermeyer, Carla 1999 Female genital surgeries: The known, the unknown, and the unknowable. Medical Anthropology Quarterly 13(1):79-105. Obermeyer, Carla 2001 “Complexities of a controversial practice.” Science 292:1305-1306.

Laurette Cucuzza: Has the module been changed to determine if there has been a trend toward medicalization of FGC?
P. Stanley Yoder: Thanks very much, Laurette. The part of the module that deals with who did the cutting─a medically trained person or a more traditional specialist─is a section that has not changed for some time. Most, if not all, DHS country reports with a section on FGC provide a figure for the proportion of women circumcised by a health professional (doctor, nurse, midwife). So that information is used to evaluate the degree of medicalisation that has occurred.

Shayne Bell: What are some success stories of culturally sensitive ways in which FGC has been replaced by another respected, but non-violent rite of passage?
P. Stanley Yoder: This is a good question to ask, Shayne, for several groups have sought to replace the current ritual aspects that include FGC with a ritual without cutting. The efforts in Kenya have gotten some publicity the past few years. The association called Maendeleo Ya Wanawake in Kenya, in collaboration with PATH, an American development assistance agency that receives lots of funding from USAID, tried to establish such “alternative rites” in 1999 and 2000 in at least three districts. I do not know if they have continued or not. An evaluation of those efforts (Chege, Askew, Liku, 2001) showed a very mixed picture of success. I do not think that these efforts would qualify as “success stories,” though participants may have a different opinion. There may well be other programs in African countries that have succeeded. However, I am not very optimistic about such efforts. Such efforts demand a great deal of time, attention, resources, personnel, and a clear vision of local priorities. So I am not aware of any success stories. If you have any, please let me know.

Grace Uwizeye: It has been difficult to measure impact of many activities carried out to end the practice. What indicators can be most useful for evaluating impact that would highlight that the practice has been abandoned? How would this be measured?
P. Stanley Yoder: This is an excellent question, Grace. The main indicator of abandonment in a particular society is the proportion of girls of a certain age, and of women, who have not been cut. Let’s say that in country X, 95% of girls who are circumcised these days are cut by the age of six. So if we interviewed a representative sample of all women aged 15 to 49, as do surveys such as the DHS and MICS, and we ask if they had been circumcised, and we also have information about girls 7-14 years old, then we could tell what percentage of the girls and women were circumcised. The short answer to your question: population-based surveys among women.

Francoise Ngollo: I know that there is zero tolerance for FGM in the United States; but I was wondering before the Zero tolerance Policy, was it any statistics or percentage on how many women/girls were circumcised in their country but living in the US??
P. Stanley Yoder: Thanks for the question, Françoise. I have never seen any statistics about the proportion of immigrants in the US, or Canada, or any European country, who have been circumcised. There have been a number of efforts to approximate such proportions. For example, there are Somali immigrants living in Norway. If we assume that the total number of Somali women is known, and if we know the age of immigration of these women, and we assume that Somali girls are not cut in Norway, we could approximate the percentage of Somali women who have been cut, since the FGC prevalence in Somalia is known. To answer your question we would need to be able to estimate the number of immigrant women who came to the US already circumcised, and determine how many girls have been circumcised in the US. That information is not available. I do not think it possible to calculate the statistics of how many circumcised women live in the US. If we knew how many women came to the US after they had turned 15 from each of the countries where FGC is practiced, we could arrive at a guess of the number of women who arrived in the US after having been circumcised. But it would be only a guess, for the people who move to the US are not likely to be typical of the population. The Italian agency called AIDOS based in Rome has been working toward understanding how many circumcised women live in Italy, but there are many challenges.

Charlotte Feldman-Jacobs: In Kakenya Ntaiya’s audio interview on the PRB website www.prb.org/Journalists/Webcasts/2011/fgm.aspx, she alludes to the possibility that FGM/C laws have driven the practice underground and that the prevalence is not decreasing but being driven underground. Would the data reveal that?
P. Stanley Yoder: Thanks for the question, Charlotte. There has been speculation in a number of countries about the effect of a law against doing FGC, but very little evidence. When Senegal passed their law against FGC, some people said that mothers would just take their girls to The Gambia to get them circumcised. When the DHS in Burkina Faso found that the FGC rate was higher in 2003 (77%) that in 1998 (72%), there was some discussion in Burkina about women being afraid to admit that they were cut. But I do not know of any way that statistics on FGC prevalence in any country would show that FGC went underground. One would need to conduct a series of interviews to the people who do the cutting to find out if that has occurred. Survey methods will not provide such information.

Julia Lalla-Maharajh: The most frequently used figure of girls at risk of cutting a year is 3 million, yet we know from your work that this represents just 21 out of 28 practising African countries where we have data. How can we start using a figure that is more representative of the girls who are at risk around the world, particularly given the high numbers of girls at risk in areas such as Indonesia, Malaysia and Kurdistan?
P. Stanley Yoder: Thanks for the question, Julia. If I recall correctly, that figure of three million does cover nearly all 28 countries. There is no way of knowing how many girls are at risk around the world, since there are no data on how many immigrant women have circumcised their daughters. On the other hand, while Indonesia has a very large population (around 240,000,000), the group(s) who do FGC are very small indeed. So it would not be accurate to say that there is a “high number of girls at risk” in countries such as Indonesia, Malaysia and Kurdistan. I understand the desire to have data that is complete as possible for the numbers of girls at risk, for anti-FGC programs need data of that kind to generate support.

Wanda Finch: 1) What is known about the number of women and girls who live in the US and may have been returned to their native country to have the practice? 2) What strategies should be considered to meet the needs of circumcised women and girls or women/girls at risk for FGC who live in the US?
P. Stanley Yoder: Thanks, Wanda. We know nothing about the number of girls or young women who may have been returned to their country of origin to undergo FGC. I doubt it would be possible to even determine how many young girls leave the US to travel to countries where FGC is practiced. Where would we obtain such information? Some girls are American citizens, some are not. Records of who leaves the US might exist, but I doubt that information about the destination of girls leaving the US is available. You also ask about meeting the needs of circumcised women in the US. These women need to be seen by gynecologists who have been trained to address the physical and mental needs of women who have been cut, so in cities or regions where there is a substantial number (>100???) number of circumcised women, the state should provide such training. Some women need minor surgery to correct a medical problem. The best example of meeting the needs of such women can be found in the work of Dr. Nawal M. Nour, a gynecologist who used to work at the Brigham and Women’s Hospital in Boston (I think she still works there). She founded the African Women’s Health Centre in Boston, and she travels around the US to give talks about how to address the needs of these women. I think she received a MacArthur Genius grant perhaps three years ago.

Nicole Rodrigues: We need more detailed information and statistics on girls under 15 who are being cut.
P. Stanley Yoder: Thanks for your statement, Nicole. I do agree, but I wonder how you would use such information. For those who work with DHS and MICS data, we would say that we need information about whether girls under 15 have been cut so that we can better establish trends in FGC prevalence over time. That is, having such data about girls under 15 allows us to monitor trends in FGC prevalence somewhat closer to the present than our data about women 15-49 years of age. I do not know if that is your reasoning or not. That is why first UNICEF, then Macro, decided to ask questions in the MICS and the DHS FGC modules about all living daughters less than 15 years old of women in the sample. We also find out who did the cutting (for rates of medicalisation) and if they were sewn shut (rates of infibulation).

Cristiana Scoppa: In the recent Egypt DHS new question about the status of girls (daughters) was introduced to capture the trend in abandonment of the practice. Will these questions be used in all DHS on FGM in the future? What are Macro International’s expectations about the impact of these data?
P. Stanley Yoder: Thanks much for asking the question, Cristiana. The FGC module used in the 2008 Egypt DHS is different from others in that information is collected for all daughters less than 19 years old, in that there are questions about having heard news of FGC in the media, and there are a series of statements about FGC that ask the respondent to agree or disagree with the statements. With regard to daughters, the revised FGC module used now by DHS asks for information about all daughters less than 15 years old, and that will be used in all countries that conduct a DHS. At least that is the plan. We do not, however, ask about the intention to circumcise if a daughter has not been cut, as they did in the 2008 DHS in Egypt. I can send you a copy of the FGC module if you like.

Jeanne Humble: What is the relationship between FGM (including clitoridectomy, excision and infibulation) and the spread of AIDS? Are females who have FGM more likely to get AIDS than females who have not had FGM? If so, why? Is it due to the tearing of scar tissue which allows the HIV to enter the system more easily?
P. Stanley Yoder: There have been a number of studies that have tried to establish a relationship between FGC and the spread of HIV infection, but no strong evidence has been found to connect the two. Women who have been cut are not more or less likely to get HIV than those who have not been cut unless the FGC has left lesions in the genital area, or scar tissue has been torn during sex. That does sometimes happen, and in such cases, a woman could more easily absorb the infection.

Dorathy Akwugo Isu: What efforts are being made to equip local NGOs in Nigeria to collect or receive relevant data needed to tackle FGM in their rural communities?

P. Stanley Yoder
: Thanks, Dorothy. I do not know the answer. You should be able to find out by contacting the government agency that implemented the most recent DHS (2008) in Nigeria, the National Population Commission.

Julia Lalla-Maharajh: Recent WHO studies show that FGC is harmful to babies, leading to an extra 1–2 perinatal deaths per 100 deliveries. Are there other sources of data around perinatal deaths? Also, if very young girls are being cut and are therefore at risk of haemorrhage or infection, how can these numbers be represented?
P. Stanley Yoder: Thanks, Julia. The sources of perinatal death statistics are different for each country, but some countries have a health information system that produces statistics of perinatal deaths. Some DHS surveys, as well as other studies, have included verbal autopsies of childhood deaths, and thus can sometimes be useful. I do not think that countries with large numbers of girls cut would have records of infection or haemorrhage due to FGC. I doubt the health information systems are sufficiently detailed for that.

alan f blazek: As far as patriarchal or matriarchal community, village, or tribe leaders are concerned, are there instances where they, desirous of the best defense, opt for 21st Century precedent and law? Bouncing between tradition and the present, might this be a way to say,”You can’t have it both ways, so application of law must be consistent for all circumstances? So, cutting is history? Would not tradition be tossed in lieu of precedent or international law? European/US legal system
P. Stanley Yoder: I would like to answer your question, Alan, but I am not able to understand what you are asking. Sorry.

Jose E. Vega: What is the origin of this practice? I once heard a colleague comment that Europeans began the practice and spread its use during the colonial period.
P. Stanley Yoder: Thanks, Jose. No one is sure of the origin of the practice, but there are references to the practice in Egypt well before the Christian Era (CE), so it goes back more than 2,000 years. The practice spread westward through parts of North Africa, but we do not know the timing. There is evidence from accounts by chiefs that it arrived in southern Guinea or northern Liberia around 1900.

Joanna Vergoth: In 1997 the Center for Disease Control and Prevention in Atlanta estimated that 168,000 women and girls living in the US had had their genitals cut or were at risk of suffering FGM/C. What are the most recent statistics we have regarding FGM/C practicing immigrant communities in the US?
P. Stanley Yoder: Thanks for asking, Joanna, and I wish I could answer. I have never seen any statistics, recent or ancient, on FGC prevalence in the US. I was not aware of the CDC report. If they provide figures for women and girls in the US who have been or, or are at risk, they must have simply combined figures for immigrants from certain countries. I would not have faith in such figures.

Dr Saad Abdelrahman: No FGM in Saudi Arabia especially Mecca & Madina where Prophet Mohamed lived & inspite of this type 1&2 FGM in Sudan is called Sunna circumcision(deeds of prophet Mohamed ,How this started?
P. Stanley Yoder: We know that FGC predates islam by hundreds of years. So essentially, there is no connection between FGC and islam except that certain Muslim communities now practice it while others do not. As earlier mentioned, there is written evidence of FGC as a practice well before the Christian Era in what is now Egypt.

Emeka Nwosu, Nigeria: Is there a relationship between female genital mutilation and the disease known as VVF?
P. Stanley Yoder: Thanks, Emeka, but I have no idea what the disease known as VVf might be.

John Townsend: Have efforts such as donor coordination, INTACT or other evidence networks, and global advocacy, had a notable effect on FGM/C eradication efforts?
P. Stanley Yoder: Thanks for the question, John. The question is somewhat broad. Certainly donor collaboration has been effective in publicizing the existence of FGC and has succeeded in framing the practice as a human right violation in some social contexts. UNICEF has emphasized this angle in some of its publications. The coordination has also facilitated the passing of laws against the practice in some countries. Overall, it seems that UNICEF has been the most active in supporting anti-FGC programs in countries in Africa.

Rene: What do you consider to be the most critical indicators to measure the abandonment of FGM/C? Is it feasible to collect the data on a regular basis by national/local partners?
P. Stanley Yoder: Thank you, Rene. The main indicator to use for assessing progress in the abandonment of FGC is the prevalence of FGC among girls and women who have passed the age at which girls are circumcised. The most useful indicator is FGC prevalence among women 15-49 years of age. Data on prevalence require samples representative of the female population, so local partners could conduct surveys if they have the funds and knowledge necessary.

Nahla Abdel-Tawab: I think one question that could be added to the DHS module is whether women are aware of legislations against FGM in their countries. Also, it would be useful to find out from respondents who are the family/community members who support FGM (husband, mother, mother in law, religious leader, doctor, nurse, TBA,etc). Are there currently any questions addressing these issues?
P. Stanley Yoder: There are no questions in the current FGC module related to women’s awareness of legislation against FGC in their country. Such a question may have been asked by one or two countries in the past, but I am not sure. We ask the woman’s husband if his religion requires FGC, and we ask if he thinks the practice should continue. We do not ask anything about the support of other family members. The DHS surveys focus on the knowledge and the experiences of the women in the sample. We would not know how to analyze or interpret a woman’s description of the relative support, whatever that would be, that other family members might give the practice.

Donna Clifton: I notice that results from the latest round of UNICEF’s Multiple Indicator Cluster Surveys have started to be released. These surveys often contain data on FGM. Do DHS and UNICEF work together to see that the questionnaires are comparable across countries?
P. Stanley Yoder: Thanks for this important question. The honest answer is Yes. Macro and UNICEF, or DHS and MICS, have collaborated for some years now in the formulation of our questions in most domains, including FGC. It is safe to say that the large majority of the questions in DHS and MICS are the same. DHS has recently revised our FGC module to move closer to the MICS version, for we thought that collecting data on all living daughters less than 15 years old would be worth doing. We use the cohort “less than 15 years old” because those who are 15 and older are eligible for the general sample.

Jay Gribble: Is there any evidence that certain groups underreport FGM—similar to groups underreporting gender-based violence? Similarly, is there any evidence that women either underreport or overreport the type of cutting they experience?
P. Stanley Yoder: Thanks for the question, Jay. We do wonder about underreporting from time to time, but we do not have evidence that it occurs. Such evidence would require both participation in a survey and a gynecological exam. While such a study could be conducted, hypothetically, it would be extremely expensive, so not likely to be done. One study in Navrongo, Ghana (the DSS in the north) conducted a panel study with a survey questionnaire several years apart that asked questions about whether the woman had been circumcised. They found that 5% of women gave an different answer the second time around.

Nicole: Dr. Yoder, You helped me tremendously as a master’s student in my work in Mali with matrones. thank you. My question now is how you view the relative success (or lack thereof) of countries that make the practice illegal. Is there any evidence this works?
P. Stanley Yoder: Thanks for the question, Nicole. I have not seen any such evidence. There are two reasons for the lack of evidence. One, it would require that a researcher examine trends in FGC prevalence in a number of countries, and evidence that a reduction of FGC prevalence be due to the law. How would one establish that? How does one attribute causality to an outcome that is influenced by so many factors?

Cody Donahue: Hi Stan, two questions: 1. Can you describe the role communities themselves can be playing in monitoring the practice of FGC and the process of abandonment? 2. What kinds of questions might we be working with the communities to answer to detect a sustainable shift away from FGC? Thanks for your insights!
P. Stanley Yoder: These are not easy questions to answer, Cody. First, what is your image of “community”? Is it several villages side by side with 1500-200 people? Is that a community? Sounds fine to me. I would think that any association in the community, one whose members are all from that community, could monitor the occurrence of FGC as girls are cut. That is, it should be possible to find out who does the cutting, and then verify how often this occurs. It would be better for the association to take an ostensibly neutral stance toward FGC in order to more easily follow events. I am not sure what you are asking in #2. If you are asking about how to detect progress, you might be able to do a study every other year in primary schools to determine the proportion of girls cut already. We should expect some time to elapse between leaders saying that they no longer support doing FGC in their villages, and the actual abandonment of the practice.

Fatoumata Bathily: What do you think of Dr. Fuambai Ahmadu, who is a pro-FGC?
P. Stanley Yoder: Fatoumata, I do not agree that Fuambai is pro-FGC. She does disagree with certain positions taken by anti-FGC activists, I know. Fuambai is a good friend of mine. We have occasionally served on the same panel at academic conferences. I do admire her courage. I hope her book on initiation is published very soon.

Wanda Jones: Could the DHS questions be used in the US, amongst NGOs in or serving practicing immigrant communities? Also, what efforts are being undertaken to understand the situation in Colombia, where the practice was recently revealed amongst an isolated indigenous population? Happy to send you a copy of the 1997 paper—we loaded it with caveats about our assumptions, but it was driven by a Congressional mandate.
P. Stanley Yoder: Thank you, Wanda. I would love to see the 1997 report. The DHS questions would not be suitable for use in immigrant populations. If you wanted to collect information about the FGC status of immigrant women in the US, you would need to work through local social service organizations that serve mainly female immigrant and that might, just might, help you identify possible respondents. Or they may not. I have no information about the situation in Colombia. Sorry.

Nicole Rodrigues: How many infant deaths happen because of complications arising from damage to birth canal and vulvas of cut women?
P. Stanley Yoder: Thanks, Nicole. No one knows, but I would think very very few. The 2006 WHO report may have a few comments on that, but I am not certain.

Abdelhadi Eltahir: Many thanks to PRB for the excellent work in addressing the problem of FGC/M; and for coordinating this session. Many thanks Stan for the persistent work that continued to do over the years, all my experiences working with you in this area are inspiring. Q. While the 2010 data sheets brings a lot of hopes when comparing the prevalence of FGC among 15-19 age group with other age groups, the situation in Gambia and Eritrea didn’t show a change or reduction…Could that be due to the survey method, particularly a small decline is expected to happen as a result of social changes, or perhaps there are other confounding factors in these two countries.
P. Stanley Yoder: Thank you, my friend. I have been corresponding with folks at WHO recently about the decline in FGC prevalence among cohorts of women over time, and The Gambia was mentioned as an example of no decline. Same with Guinea-Bissau. I do not think the lack of decline is due to a survey method. I think it is safer to assume that from 1985 to 2005, there was little or no change in the practice in these countries. Then the question becomes: Why not? It is better to ask folks who know the situation better. I had one thought about this the other day. I wonder if abandonment is not easier in large countries such as Kenya with lots of social mobility, and if abandonment is more difficult in very small countries. I can also think of people telling me that it should be easier to persuade people to stop in small countries. I do think that social mobility plays a large role.